Managing Care Transitions in Medicaid: Spotlight on Community Care of North Carolina

This second of three case studies examining key operational aspects of coordinated care initiatives in Medicaid focuses on Community Care of North Carolina’s (CCNC) Transitional Care Program (TCP). CCNC is a medical home program that serves 83% of all North Carolina Medicaid beneficiaries. Individuals are enrolled in a practice that participates as a medical home in their community. Regional networks provide practice support to improve care management, with training, data, and tools provided by the central CCNC office, and hire care management staff, who are assigned to the medical home practices. The TCP, which is an enhancement of CCNC, identifies high-risk CCNC enrollees when they are admitted to a hospital, and plans, coordinates, and arranges their transition back to the community. The idea is that robust discharge and transition planning for patients with complex needs can reduce their risk of emergency department use and readmission. The TCP has three main elements. CCNC’s Informatics Center provides the regional networks and medical home practices with real-time data on Medicaid inpatient admissions and the characteristics and utilization history of the patients. The networks receive additional funding to hire hospital-based “embedded” care managers to coordinate transition planning with the CCNC care managers who staff the medical home practices. Training and tools support the embedded care managers.

Key Themes

The CCNC infrastructure provided the foundation for the TCP. Implementation of the TCP was relatively rapid because much of the infrastructure was already in place, including medical home practices and regional networks supported by data analytics and training. The state added a new cadre of hospital-based care managers, expanded central office functions and financing for data and information capability, and developed new models of care and training to support the system.

Obtaining timely hospital data is critical, but challenging. CCNC worked with the state hospital association to get hospitals to provide real-time feeds of admissions data to the Informatics Center. Regional networks must make agreements with individual hospitals that do not participate in the Informatics Center exchange to obtain their Medicaid admissions data, which are often transferred through paper records that are hard to manipulate and sort. Diagnostic information on admissions records may not be complete or accurate.

A strength of the TCP is the blend of common program features and local customization. While CCNC guidance and training on key aspects of the transitional care model apply statewide, regional flexibility is also built in. Care managers are hired locally by the regional networks, which can adapt the program and innovate based on local conditions. CCNC’s convening function facilitates sharing of lessons across regions.

The TCP enjoys strong support. Care managers view the TCP as an integral part of CCNC. In addition, the TCP has catalyzed interaction among community groups that share its goals. Hospitals, individual practices, and community organizations that serve the same patients work closely with regional network staff to manage transitions.

Looking Ahead

A recent evaluation shows that the TCP has had considerable success in reducing readmissions among beneficiaries who receive transitional care. As policymakers seek effective approaches to delivering coordinated care, especially for Medicaid beneficiaries and others with high needs and costs, North Carolina’s TCP demonstrates that a robust network of primary care practices that operate as medical homes, supported by health information technology, care managers, and care management tools, can expand the reach of patient-centered care beyond the walls of the doctor’s office and the hospital into the community, reducing hospitalizations for high-risk individuals.